Specialty pharmacy requirements - UHCprovider.com

1 Specialty pharmacy requirements For UnitedHealthcare commerical plan members Medication sourcing requirement . all outpatient providers Places of service: Outpatient facility, physician office, home, ambulatory infusion To support the provider/patient relationship in managing rare and complex chronic conditions, we require care providers who participate in UnitedHealthcare commercial plans to follow Specialty pharmacy requirements when obtaining certain Specialty medications covered under the member's medical benefit. To meet the requirements , you must order certain medications from the Specialty pharmacies listed in the table below. Please note: The requirements do not apply to UnitedHealthcare West members. Therapeutic class Brand name Specialty pharmacy Botulinum toxin A and B Botox , Dysport , Myobloc , Xeomin Optum pharmacy ( Specialty ).

2 Phone: 855-242-2241. Fax: 877-342-4596. Enzyme replacement therapy Brineura Orsini Pharmaceutical Services Phone: 800-240-9572. Fax: 847-427-7976. Gene therapy Luxturna Accredo Health Group Phone: 877-222-7336. Fax: 866-579-4655. Immune modulator Gamifant Biologics, Inc. Phone: 800-850-4306. Fax: 800-823-4506. RSV prevention Synagis Optum pharmacy ( Specialty ). Phone: 855-242-2241. Fax: 877-342-4596. Spinal muscular atrophy Spinraza Accredo Health Group Phone: 877-222-7336. Fax: 866-579-4655. Peyronie's disease, Xiaflex * US Bioservices Dupuytren's contracture Phone: 888-518-7246. Fax: 888-418-7246. *Effective for dates of service on or after April 1, 2021. PCA-1-21-04577-PH-WEB_12152021. Therapeutic class Brand name Specialty pharmacy Spinal muscular atrophy Zolgensma Accredo Health Group Customer Service phone: 877-787-8704.

3 Clinician phone: 800-987-5254. Fax: 877-327-8413. Orsini Pharmaceutical Services, LLC. Phone: 800-697-5048. Fax: 877-471-5704. Medication sourcing expansion requirement outpatient hospital providers only The requirement to use a Specialty pharmacy applies to additional drugs administered in an outpatient hospital setting. To meet the requirements , outpatient hospital providers must order the medications listed in the chart from the indicated Specialty pharmacies, unless otherwise authorized by UnitedHealthcare. Effective for dates of service starting Dec. 1, 2021, to include 1 more Specialty drug Effective for dates of service starting Jan. 1, 2022, to include 2 more Specialty drugs At this time, these requirements apply to UnitedHealthcare commercial plans, but do not apply to UnitedHealthcare West, UMR, Student Resources, UnitedHealthOne Golden Rule and Sierra plans.

4 UnitedHealthcare Oxford commercial plans are subject to a separate Specialty pharmacy requirement, which can be viewed at > Policies and Protocols > Commercial Policies >. UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies > Specialty pharmacy for Certain Specialty Medications Administered in an Outpatient Hospital Setting Oxford Clinical Policy. The Specialty drug and pharmacy list below does not apply in the following states/territories. Alaska, Hawaii, Kentucky, Louisiana, Maryland, Puerto Rico, Rhode Island, Utah and Virgin Islands The list below applies in all other states. Specialty drug and pharmacy list Medication Effective date Therapeutic class Code Specialty pharmacy name Caremark (CVS Specialty ). Actemra Oct. 1, 2020 Inflammatory conditions J3262 Option Care Health Optum pharmacy ( Specialty ).

5 Adakveo Oct. 1, 2020 Sickle cell disease J0791 Optum pharmacy ( Specialty ). Accredo Health Group AllianceRx Walgreens Prime Enzyme replacement Caremark (CVS Specialty ). Aldurazyme Oct. 1, 2020 J1931. therapy Option Care Health Optum pharmacy ( Specialty ). Orsini Pharmaceutical Services Amondys-45 July 1, 2021 CNS agents J1426 Orsini Pharmaceutical Services PCA-1-21-04577-PH-WEB_12152021. Medication Effective date Therapeutic class Code Specialty pharmacy name Accredo Health Group AllianceRx Walgreens Prime Aralast NP Oct. 1, 2020 Alpha1-proteinase inhibitors J0256. Caremark (CVS Specialty ). Accredo Health Group Asceniv J1599. March 1, 2021 Immune globulin Accredo Health Group J1554. Avsola March 1, 2021 Inflammatory conditions Q5121 Option Care Health Accredo Health Group AllianceRx Walgreens Prime Monoclonal antibody Benlysta Oct.

6 1, 2020 J0490 Caremark (CVS Specialty ). miscellaneous Option Care Health Optum pharmacy ( Specialty ). Optum Infusion Bivigam Oct. 1, 2020 Immune globulin J1556. Optum pharmacy ( Specialty ). Accredo Health Group Cabenuva Oct. 1, 2021 HIV therapy J0741. Caremark (CVS Specialty ). Accredo Health Group AllianceRx Walgreens Prime Enzyme deficiency Caremark (CVS Specialty ). Cerezyme Oct. 1, 2020 J1786. (Gaucher disease) Option Care Health Optum pharmacy ( Specialty ). Orsini Pharmaceutical Services Accredo Health Group Cimzia March 1, 2021 Inflammatory conditions J0717. Optum pharmacy ( Specialty ). Cinqair Oct. 1, 2020 Asthma J2786 Optum pharmacy ( Specialty ). Accredo Health Group Caremark (CVS Specialty ). Crysvita March 1, 2021 Endocrine J0584. Orsini Pharmaceutical Services PANTHERx Rare pharmacy Accredo Health Group Cutaquig Oct.

7 1, 2020 Immune globulin J3590 Option Care Health Optum Infusion Accredo Health Group Option Care Health Cuvitru Oct. 1, 2020 Immune globulin J1555. Optum Infusion Optum pharmacy ( Specialty ). PCA-1-21-04577-PH-WEB_12152021. Medication Effective date Therapeutic class Code Specialty pharmacy name Accredo Health Group AllianceRx Walgreens Prime Enzyme replacement Caremark (CVS Specialty ). Elaprase Oct. 1, 2020 J1743. therapy Option Care Health Optum pharmacy ( Specialty ). Orsini Pharmaceutical Services Accredo Health Group Enzyme deficiency Elelyso Oct. 1, 2020 J3060 Caremark (CVS Specialty ). (Gaucher disease). Orsini Pharmaceutical Services Accredo Health Group AllianceRx Walgreens Prime Entyvio Oct. 1, 2020 Inflammatory conditions J3380 Caremark (CVS Specialty ). Option Care Health Optum pharmacy ( Specialty ). Option Care Health Exondys 51 Oct.

8 1, 2020 CNS agents J1428. Orsini Pharmaceutical Services Evkeeza Oct. 1, 2021 Rare conditions J1305 Orsini Pharmaceutical Services Accredo Health Group AllianceRx Walgreens Prime Enzyme replacement Caremark (CVS Specialty ). Fabrazyme Oct. 1, 2020 J0180. therapy Option Care Health Optum pharmacy ( Specialty ). Orsini Pharmaceutical Services Accredo Health Group AllianceRx Walgreens Prime Fasenra Oct. 1, 2020 Asthma J0517. Caremark (CVS Specialty ). Optum pharmacy ( Specialty ). Accredo Health Group AllianceRx Walgreens Prime Gammagard Caremark (CVS Specialty ). Oct. 1, 2020 Immune globulin J1569. Liquid Option Care Health Optum Infusion Optum pharmacy ( Specialty ). AllianceRx Walgreens Prime Option Care Health Gammaked Oct. 1, 2020 Immune globulin J1561. Optum Infusion Optum pharmacy ( Specialty ). PCA-1-21-04577-PH-WEB_12152021.

9 Medication Effective date Therapeutic class Code Specialty pharmacy name Accredo Health Group AllianceRx Walgreens Prime Gammaplex Oct. 1, 2020 Immune globulin J1557 Option Care Health Optum Infusion Optum pharmacy ( Specialty ). Accredo Health Group AllianceRx Walgreens Prime Gamunex-C Oct. 1, 2020 Immune globulin J1557 Option Care Health Optum Infusion Optum pharmacy ( Specialty ). Accredo Health Group Givlaari Oct. 1, 2020 Blood-modifying agents J0223. PANTHERx Rare pharmacy Accredo Health Group AllianceRx Walgreens Prime Glassia Oct. 1, 2020 Alpha1-proteinase inhibitors J0257. Caremark (CVS Specialty ). Option Care Health Accredo Health Group AllianceRx Walgreens Prime Hizentra Oct. 1, 2020 Immune globulin J1559 Option Care Health Optum Infusion Optum pharmacy ( Specialty ). Accredo Health Group AllianceRx Walgreens Prime HyQvia Oct.

10 1, 2020 Immune globulin J1575 Option Care Health Optum Infusion Optum pharmacy ( Specialty ). Accredo Health Group Ilaris Oct. 1, 2020 Immune modulator J0638. Caremark (CVS Specialty ). Accredo Health Group Ilumya Oct. 1, 2020 Inflammatory conditions J3245 Caremark (CVS Specialty ). Optum pharmacy ( Specialty ). Accredo Health Group Inflectra Oct. 1, 2020 Inflammatory conditions Q5103 Option Care Health Optum pharmacy ( Specialty ). Accredo Health Group AllianceRx Walgreens Prime Enzyme replacement Caremark (CVS Specialty ). Kanuma Oct. 1, 2020 J2840. therapy Option Care Health Optum pharmacy ( Specialty ). Orsini Pharmaceutical Services PCA-1-21-04577-PH-WEB_12152021. Medication Effective date Therapeutic class Code Specialty pharmacy name Accredo Health Group Krystexxa Oct. 1, 2020 Anti-gout agents J2507 Caremark (CVS Specialty ).